argonaut insurance company peleus … · tprs‐app230‐0817 page 4 of 14 exposure/operation...

TPRS‐APP230‐0817 of 14

IMPORTANT NOTICE

If CLAIMS MADE is selected (checked) as the Coverage type for any line of business included on this application, that section of the application is for Claims‐Made coverage. Read all provisions of the policy carefully.

BY COMPLETING THIS APPLICATION, THE APPLICANT IS APPLYING FOR COVERAGE WITH EITHER ARGONAUT INSURANCE COMPANY, A LICENSED INSURER OR PELEUS INSURANCE COMPANY, A SURPLUS LINES INSURER.

Submission Requirements Completion of this application and any supplemental applications Up-to-date schedules including Property COPE information, Autos with Original Cost New Five (5) years (plus current year) of currently valued loss runs and/or TPA Most Current Budget

GENERAL INFORMATION

Entity Name FEIN Entity Population

Street Address City State County Zip Code

Insurance Contact/Title Contact Phone

Contact Email Address

Key Dates Effective Date Bid Date (if any) Agency Need-by Date

Submitting Agency Agency Phone

Producer / Agency Contact Email Address

Street Address City State Zip Code

Claims Administrator Name of Third Party Administrator (TPA) Firm Phone

Primary TPA Contact Email Address

Street Address City State Zip Code

PUBLIC ENTITY RETAINED LIMIT LIABILITY APPLICATION


PREMIUM AND LOSS HISTORY

Line Check if

Requested Expiring Premium

Carrier Deductible/SIR Policy Limit

General Liability $ $ $

Public Officials’ Liability $ $ $

Employment Practices Liability $ $ $

Law Enforcement Liability $ $ $

Auto Liability $ $ $

Auto Physical Damage $ $ $

Excess Liability $ $ $

Other: $ $ $

Other: $ $ $


GENERAL LIABILITY Coverage type: Per Occurrence Limit: $_________________ Annual Aggregate: $_________________

SIR: $_________________

General Liability Exposures

Supplemental questionnaires required for these exposures are indicated in the column on the right.

Exposure/Operation Exposure

Check if Yes

Subcontract to Others?

Check if Yes

Separate Legal

Entity / Separately

Insured

Check if Yes

Supplemental Applications:

https://www.argolimited.com/trident/applications/

Cemetery

Dams Complete TPRS-SUP197 Supplement

Fire Department – Paid and/or Volunteer

Complete TPRS-SUP198 Supplement

Firearms Range - Public Use

Certified Range Master on Staff? Yes No

Housing Authority/Habitational

Active Landfill / Dump / Refuse Site / Incinerator

Complete TPRS-SUP199 Supplement

Garbage/Recycling Services

Nursing Home Insured Separately? Yes No

Insured Separately? Yes No Home Health Care

Public Facilities Convention/Civic Center/Stadium

Describe:

Recreational Activities Complete TPRS-SUP194 Supplement

Schools Complete TPRS-SUP201 Supplement

Social Services a. Shelter (Women or

Children), Halfway House

Describe operation:

b. Foster Care


Exposure/Operation Exposure

Check if Yes

Subcontract to Others? Check if Yes

Separate Legal

Entity / Separately

Insured Check if Yes

Supplemental Applications:

https://www.argolimited.com/trident/applications/

Special Events a. Carnival, Fair, Parade

Mechanical Rides/Devices Yes No

Liquor Service Yes No

b. Fireworks

Licensed Pyrotechnician Yes No

Fire & EMS onsite Yes No

Streets/Roads/Bridges

The following apply to Bridges: # of Bridges _______

Attach list of any bridges closed, condemned or not meeting inspection standards.

Inspection & Maintenance Program Yes No

Stored Records of Maintenance Performed Yes No

Inspection for Missing Signage Yes No

Utilities a. Electric

Complete TPRS-SUP192 Supplement b. Gas

c. Sewer

d. Water

Wharf/Piers

Formal Wharf/Pier inspections? Yes No

Marina

Zoo

Other: Describe:


Contractual Risk Transfer

Yes No Legal Representative reviews all contracts?

Yes No Require to be named as Additional Insured?

Yes No Legal Counsel on staff or dedicated outside Counsel?

Yes No You require Insurance Limits of contractors equal to yours?

Emergency Services

1. Fire Department Personnel: Number of Regular Personnel ____________

Number of Volunteer ____________

2. Are mutual aid agreements in place with neighboring communities? Yes No

3. EMTs/Paramedics/EMTAs: Number of Paid ____________

Number of Volunteer ____________

4. Fire/EMS Dispatch:

a. Does your department handle its own dispatch? Yes No

If “No”, who handles dispatch? ______________________________________________________________________

b. Are incoming calls to dispatch recorded? Yes No

c. What dispatch services are provided? Police Fire EMS

d. How long are tapes retained? ______________________________________________________________________

e. Are training/certification procedures in place? Yes No

f. Is dispatch service provided to outside entities? Yes No

Unmanned Aerial Systems (Drones) Number of Drones: ________

Intended Use Weight

1.

2.

3.

4.

5.

Are drones operated within Federal, State, and local requirements? Yes No


PUBLIC OFFICIALS’ LIABILITY A. Coverage and Limits

1. Coverage type: Claims-Made, Retroactive Date: _________________ or Occurrence

2. Each Wrongful Act Limit: $_________________ Annual Aggregate: $_________________

SIR: $_________________

B. General Information

1. Policies and Procedures

a. Are Officials trained in public meeting protocols? Yes No

b. Does the entity engage legal counsel on potential conflicts of interest? Yes No

c. Policy in place around public officials speaking to the media, social media? Yes No

2. Planning and Zoning, Land Use

a. Does the entity have a formal written zoning and zoning appeal process? Yes No

b. Is Legal Counsel on cases when statutes/ordinances need interpretation? Yes No

Have any of the following occurred within the last three (3) years?

a. Disputes involving the taking or condemnation of property? Yes No

b. Disputes alleging the wrongful approval/denial of building or zoning permits? Yes No

If “Yes”, please provide details:

EMPLOYMENT PRACTICES LIABILITY

A. Coverage type: Claims-Made, Retroactive Date: _________________ or Occurrence

B. Each Wrongful Act Limit: $_________________ Annual Aggregate: $_________________

Deductible: $_________________ or SIR: $_________________

C. Employee Information

1. Number of: Full-Time Employees: Part-Time Employees:

2. What was the annual employee turnover rate for the last three (3) years?

Current Year: % 1st Prior Year: % 2nd Prior Year: %

3. How many involuntary employment terminations* have occurred in the past three (3) years?

Current Year: % 1st Prior Year: % 2nd Prior Year: %


D. Disputes/Claims Information

Have any of the following occurred within the last three (3) years?

1. Disputes involving integration, segregation, discrimination or violation of civil rights? Yes No

2. Disputes alleging wrongful treatment in employee hiring, employment conditions, Yes No remuneration, advancement of employment or termination of employment?

If “Yes”, please describe:

E. Policies and Procedures

1. Entity conducts prior employment check on all new hires? Yes No

2. Does the entity have an employee handbook? Yes No

3. Is employee handbook signed by all employees? Yes No

4. Latest Revision Date of employee handbook? _________________________

5. When did legal counsel last review the employee handbook? _________________________

6. Does the entity have a posted anti-discrimination policy? Yes No

7. Does the entity have written policies and procedures with regard to the following? (Please check all that apply)

Policy Last Revision Date Policy Last Revision Date

Hiring Sexual Harassment

Discrimination Disciplinary Actions

Grievance Procedures Internet Usage

Termination Social Media

Medical / Unpaid Leave Disability and ADA

F. Employment Practices Controls and Employee Performance

1. Does the entity provide training for all new supervisors and managers on Yes No employment and harassment policies?

2. Annual Affirmation from Employees on the following policies? (Please check all that apply):

Discrimination Social Media Internet Usage Harassment

3. Documented Employee Performance Reviews at least annually? Yes No

4. Does the entity require terminations to be reviewed by legal counsel? Yes No

G. Employment Practices Entity-wide

Do all departments (i.e. Police, Fire, School, Public Works, etc) follow the same Yes No Employment Practices policies, procedures and documentation requirements?

If “No”, describe:


LAW ENFORCEMENT

A. Coverage and Limit

Each Wrongful Act Limit: $ _______________ Annual Aggregate: $ _______________ SIR: $ _______________

B. Personnel Information

Personnel Type # of Full-time # of Part-time

Officers with power of arrest

Reserve officers with power of arrest

Duties: Traffic Events Security Other

Police canines or equines

Officer Turnover Voluntary Terminations Involuntary Terminations

Last Year

Two (2) Years Ago

C. Underwriting Information

1. Does the entity contract law enforcement services to any public or private entity? Yes No

If “Yes”, describe:

2. Does the entity belong to any multi-jurisdictional law enforcement organization Yes No such as a drug task force?

If “Yes”, describe the entity’s involvement:

3. Is the entity accredited by CALEA? Yes No

4. Percentage of Officers Using Body Camera’s: ___________%

D. Policies and Procedures

1. Does the entity have written policies governing the following?

Policy Do You Have Policy Date of Last Revision Use of deadly force Yes No

Use of non-deadly force Yes No

Pursuits Yes No

Domestic Violence Yes No

Moonlighting / Secondary Employment Yes No

Handling of persons under the influence Yes No

Handling of mentally disturbed Yes No

Armed while off duty Yes No

Use of volunteers Yes No

Suicide Screening (if you have Holding Cell) Yes No

Use of Body Cameras (usage and retention) Yes No


2. Are policies and procedures distributed to all personnel? Yes No

3. Are officers required to sign-off on Policy Manual? Yes No

4. Are these reviewed regularly by the entity’s legal counsel? Yes No

How often? _____________________________________________________________________________________

5. How does the department keep up to date on Case Law changes that may dictate policy/procedure update?

6. Has the department disciplined an officer for inappropriate Use of Force? Yes No If “Yes”, what was the discipline?

7. Who investigates use of force incidents? ______________________________________________________________

E. Training

Training Topic New Hires Annual Training Training Documented Use of Tasers and Certification Yes No Yes No Yes No Fire Arms Qualification Yes No Yes No Yes No Pursuits/Defensive Driving Yes No Yes No Yes No Handling Domestic Violence Calls Yes No Yes No Yes No Handling Mentally Disturbed Yes No Yes No Yes No Search and Seizure, Case Law Yes No Yes No Yes No Handling persons under the influence Yes No Yes No Yes No Harassment - internal Yes No Yes No Yes No Use of Body Cameras Yes No Yes No Yes No

F. Emergency Dispatching

1. Who provides dispatch services for your fire department, police/sheriff and/or EMS? ___________________________

2. Are incoming calls to dispatchers recorded? Yes No

Length of time tapes are maintained: _________________________________________________________________

3. What is the average number of calls received per month? ________________________________________________

4. Describe the training program for emergency dispatchers: ________________________________________________

G. Fleet Safety

1. Is accident investigation completes for incidents involving police vehicles? Yes No

2. Do all officers participate in driver training? Yes No

3. Does pursuit policy contain provision for supervisor discretion on terminating pursuits? Yes No


H. Jail Operations - Please include a copy of the most current State Inspection Report.

1. Do you house your own prisoners? Yes No

2. Do you house prisoners of other entities? Yes No

3. Is the entity accredited by American Correctional Association (ACA)? Yes No

Jail Holding Cell Juvenile Detention Center Other (Describe): _____________________

4. Date constructed: ____________ Date renovated/updated: ____________

5. Number of Cells: ____________ Number of Beds: ____________ Square Footage: ____________

6. Maximum State Certified Capacity Daily Average Average Length of Stay

7. Number of Full-Time Guards: _________________ Number of Part-Time Guards: _________________

8. Date of last inspection: State Corrections Fire Inspector Department of Health

9. Is the facility operating under court order or in violation of any local, state Yes No or federal codes or standards?

If “Yes”, explain:

10. Does the facility have a walk-through schedule? Yes No

If “Yes”, what is time frame? _______________________________________________________________________

11. Are Jail Medical Services contracted out? Yes No

If “Yes”, is contract in place shifting Medical Malpractice Liability to Contractor? Yes No

If “No”, describe internal medical facilities and staff:

12. Number of Suicides last thirty-six (36) months: ____________

Number of Suicide Attempts last thirty-six (36) months: ____________

13. Does the facility have audio or video surveillance systems? Yes No

Do systems monitor inmates? Yes No

I. Policies and Procedures

Policy Do You Have Policy? Date of Last Revision Frequency of Training Use of Force Yes No

Classification of Inmates Yes No

Use of Restraints Yes No

Suicide Prevention Yes No

Strip Searches Yes No

Work Release Yes No

Discipline and Grievance Yes No

Separation of Juveniles from Adults Yes No

Inmate Transportation Yes No


COMMERCIAL AUTOMOBILE COVERAGE

A. Limits

Each Accident Limit $ _________________ Hired/Non-Owned Requested Yes No

SIR $_________________ PIP/No Fault $_________________

UM/UIM $_________________

B. Underwriting Information

1. Are all owned or leased vehicles covered in this program? Yes No

2. Driver training program? Yes No

3. Accident investigation program? Yes No

4. Preventative Maintenance Program? Yes No

5. Accident investigation includes a corrective action for preventable accidents? Yes No

6. MVRs ordered prior to hire? Yes No

7. Are any vehicles designed to haul explosives, flammables, or hazardous materials? Yes No

8. Do employees drive their own vehicles to conduct the Entity’s business? Yes No

If “Yes”, do you required proof of insurance for these employees? Yes No

9. Are employees allowed to take vehicles home? Yes No

Is personal use permitted? Yes No

10. Does the entity own a garage where vehicles are serviced? Yes No

Does entity service vehicles of others? Yes No

11. Does the entity provide any type of transportation services? Yes No

Indicate type: Dial-a-Ride Fixed Transit Para Transit Other: _____________________

12. Are busses equipped with cameras? Yes No

13. Does entity own fifteen (15) passenger vans? Yes No

If “Yes”, is special training required? Yes No

14. Are criminal records checked on transportation employees? Yes No

15. Does entity transport handicapped passengers? Yes No

If “Yes”, is specific training provided? Yes No

An Auto and Property Schedule Worksheet is available for your use at https://www.argolimited.com/trident/applications/


COMMERCIAL EXCESS LIABILITY SECTION

Requested Excess Limit: $______________________________ (Maximum Limit $10,000,000)

Coverage to apply over:

General Liability Educators Legal Law Enforcement Auto Liability Employers Liability

Public Officials Employment Practices

THE FRAUD STATEMENT APPLICABLE TO YOU APPEARS ON THE FOLLOWING PAGE OF THIS INSURANCE APPLICATION. PLEASE READ IT CAREFULLY AND SIGN YOUR APPLICATION.

FS‐APP001‐0517 of 14

FRAUD STATEMENTS

FRAUD STATEMENT (Not applicable in the states mentioned below where a specific warning applies.)

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to a civil penalty or fine.

Alabama Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

Arkansas, District of Columbia, Louisiana, Rhode Island, West Virginia Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kansas Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Kentucky Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

Maryland Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey, New Mexico Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Ohio Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

FS‐APP001‐0517 Page 13 of 14

Oregon Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Pennsylvania Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Pennsylvania (Auto) Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and the payment of a fine of up to $15,000.

Tennessee, Virginia, Washington It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

New York Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

New York (Auto) Any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

SIGNATURES

DO NOT SIGN UNTIL YOU HAVE READ THE CONTENTS OF THIS APPLICATION AND THE APPLICABLE FRAUD WARNING(S).

I have reviewed the contents of this application and with my signature, I declare to the best of my knowledge that all statements herein are true and no material facts have been suppressed or misstated. I am also aware that my operation may be inspected by the Insurance Company.

APPLICANT/NAMED INSURED

APPLICANT/NAMED INSURED SIGNATURE DATE

Agent/Broker: Are you personally familiar with this Applicant’s operations? Yes No Did your office control this risk in the past year? Yes No

AGENT’S OR BROKER’S NAME AND ADDRESS TELEPHONE NUMBER LICENSE NO.

AGENT’S OR BROKER’S SIGNATURE DATE

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